Syringe Services Program Implemented During HIV Outbreak Led to Reduction of Injection-Related Risk Behaviors

Joan Duwve, MD, MPH, Associate Dean for Practice, IU Fairbanks School of Public Health

Joan Duwve, MD, MPH

A recent study found that rapid reduction of injection-related HIV risk behaviors among persons who inject drugs (PWID) in nonurban areas post-syringe services program (SSP) implementation emphasizes the need for harm reduction interventions that include access to syringes and sterile injection equipment, in addition to comprehensive HIV prevention services.

Researchers investigated the late 2014 HIV outbreak in Scott County, Indiana, which happened to be the largest outbreak among PWID in a nonurban setting in the US with 181 HIV infections diagnosed between over a period of 3 years. The SSP resulted in a rapid reduction in injection-related risk behaviors, including an 88% reduction in syringe sharing, a 79% reduction in syringe sharing to divide drugs and an 81% reduction in sharing of other injection equipment, findings that are consistent with SSPs implemented in nonoutbreak settings.

“In Scott County, this has been a really effective model for getting people who are ready for treatment into an effective treatment program, and more than 200 individuals have enrolled in treatment since it was initiated,” Joan Duwve, MD, MPH, Associate Dean for Practice, IU Fairbanks School of Public Health, told MD Mag. “When the community also participates by offering meals, clothing, support groups and other services needed, the added effect is considerable. People with substance use disorder are often stigmatized and living on the fringes of society. These programs send the message that their lives have value, and help lead them toward recovery.”

The program was initially implemented on an emergency basis in order to combat the outbreak, which happened to be the first time a program of this nature was tried in a nonurban area.

“Introducing a syringe exchange program, especially a program that is supported by the community, including law enforcement, creates a safe place for people who traditionally avoid preventive care,” said Duwve. “It is a touchpoint that meets people where they are by helping them learn how to inject safely and providing the clean supplies to prevent the ongoing spread of infections.”

Researchers routinely collected program data from the Scott County SSP and data from a qualitative study in a nonurban community where the SSP was established in response to an HIV outbreak, to compare injection-related risk behaviors and perceptions of risk before and after the emergency implementation of the program.

The data analyzed from the SSP was collected at first and most recent visit among patients with ≥2 visits, ≥7 days apart from April 4 to August 30, 2015, in order to calculate the changes in injection-related risk behaviors. Staff used a standard form to collect data on self-reported current injection-related risk behaviors, the number of sterile syringes dispensed, and estimated number of syringes returned for safe disposal. Qualitative data collected from 56 PWID recruited from Scott County was also analyzed to understand the factors contributing to the behaviors.

In the analysis, SSP clients (n=148, 62% of all SSP clients) reported significant ( P < 0.001) reductions throughout a median 10 weeks (range 1—23) in syringe sharing to inject (18%–2%) and divide drugs (19%–4%), sharing other injection equipment (24%–5%), and number of uses of the same syringe. The number of syringes returned by SSP clients increased from 0 at first visit to median 57. All qualitative study participants reported using sharps containers provided by the program.

“In Scott County, transmission of HIV and hepatitis C, and hospital admission for endocarditis all decreased once the syringe exchange program was opened,” Duwve explained. “This was an incredibly successful intervention and has effectively ended the epidemic transmission of HIV. But the costs of responding to the outbreak were high. It has been estimated that the costs of the emergency response and the ongoing treatment of those diagnosed with HIV and hepatitis C exceed $120 million. If we were to prevent individuals from getting hepatitis or HIV in the first place, we would prevent the short and long-term health effects of these infectious diseases, prevent illness, and save millions of dollars.”

Among PWID post-SSP implementation, the SSP program and in-depth qualitative interview data demonstrated rapid reduction of injection-related HIV risk behaviors. Sterile syringe access as part of comprehensive HIV prevention is important to control and prevent outbreaks.

“One of the lessons learned was that in order to reach the entire community, the syringe exchange program had to be responsive to the specific needs of the community,” concluded Duwve. “The focus groups and interviews we did provide really rich information about the history of substance use in the community, the unintended consequences of abuse-deterrent/resistant drug formulations driving the initiation of drug injecting among many we spoke with, the actual injecting practices around use of Opana ER, reasons people don’t use the syringe exchange program, the importance of having law enforcement as a partner, the critical need for evidence-based treatment accessible in the community to people who use drugs, and perhaps most importantly, the important role that harm reduction services play in increasing access to care by reducing stigma and valuing the lives of all people, including those who use drugs.”

Implementing and strengthening nonurban SSPs in the future should consider focusing on retaining existing clients, expanding access to other PWID, and strengthening referral and follow-up to address ever-changing health needs, ensuring long-term success of the programs.

The paper, “Reduction of Injection-Related Risk Behaviors After Emergency Implementation of a Syringe-Services Program During an HIV Outbreak,” was published in the Journal of Acquired Immune Deficiency Syndrome.